STATLINE

Read the Latest Issue of STATLINE

In This Issue:

• CAP: Florida Medicare Contractor Should Rescind IHC Special Stains LCD
• PQRS Users Can Now Set Up a EIDM Account
• Large Insurers Anthem, Aetna Get Bigger through Merger/Acquisition
• View the CAP's Webinar on How to Host a Lab Tour

Citing several clinical and evidentiary concerns with a proposed Medicare local coverage determination (LCD) for special histochemical stains and immunohistochemical (IHC) stains, the CAP urged the Florida Medicare Administrative Contractor First Coast to withdraw its draft LCD.

The CAP detailed its concerns in a letter urging First Coast to rescind the policy. On July 23, the College also notified CAP members in Florida, Puerto Rico, and US Virgin Islands, about the deadline to comment on the draft LCD and encouraged individuals to also submit their own comments objecting to the proposal. If adopted, pathologists and laboratories in Florida and the US territories would be affected by the LCD. The CAP remains engaged with the Florida Society of Pathologists and other stakeholders to communicate pathologists' concerns with the draft LCD to First Coast. The CAP has strongly opposed the LCD's implementation in other Medicare jurisdictions.

The LCD is of unprecedented breadth covering special stains and IHC in nine different clinical areas including breast, gastrointestinal, lung, urogenital, and skin disorders and in an equally broad number of instances requires pathologists to first review H&E stains prior to ordering special stains or IHC. The LCD was first implemented by the Medicare contractor Palmetto, which oversees administration of the Medicare program in North Carolina, South Carolina, Virginia, and West Virginia.

In the July 14 letter, the CAP's concerns included:

• The draft LCD's purported evidence base lacks credibility. It uses highly selective and partial literature citation, takes references out of context, overlooks fine points, misrepresents the opinions of national organizations, and is contrary to generally accepted guidelines. In several instances, key premises are unsubstantiated.
• The proposed policy encroaches on matters of pathologist medical judgment, failing to take into account patient characteristics that vary from practice to practice and the full range of diagnostic considerations confronting a pathologist that are evaluated in establishing the patient's diagnosis.
• As a result of its lack of clarity and reliance on retrospective claims evaluation, neither providers nor patients are able to prospectively determine if a particular service is covered for a particular patient.
• The draft LCD seems to approach the patient's diagnostic evaluation in an arbitrary fashion, potentially adversely affecting not only the efficiency with which care is delivered, but also diagnosis, clinical decisions, and treatment options. In some instances, services deemed not necessary under the draft LCD are performed to improve diagnostic turnaround time which may be lifesaving. In other instances, its provisions could direct pathologists to practices that predispose misdiagnosis, denying patients services from which they may benefit or subjecting them to harmful and unnecessary interventions, particularly in regard to some difficult-to-diagnose malignancies.

Read the full letter from the CAP.

The CAP will continue to provide updates on this issue through STATLINE as more information becomes available.

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The Centers for Medicare & Medicaid Services (CMS) has developed a new system to view feedback reports from the Medicare program.

The Individuals Authorized Access to CMS Computer Services (IACS) can no longer be used to access a group or solo practitioner's Quality and Resource Use Reports (QRURs). Beginning July 13, physicians started using the Enterprise Identity Management System (EIDM) on the CMS' website.

For questions about setting up an EIDM account, contact the QualityNet Help Desk Monday through Friday from 8 AM to 8 PM ET by phone at 866-288-8912 (TTY 877-715-6222), fax at 888-329-7377, or qnetsupport@hcqis.org. Additional information on accessing QRURs is available on the How to Obtain a QRUR web page.

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With two of the largest insurance company deals to date having occurred in July, the health care industry is experiencing unprecedented consolidation among large health plans covering over 85 million Americans' medical coverage.

The deals are both not expected to close until the second half of 2016 if they pass regulatory approvals and other requirements. Should they both close, the health insurance industry would drop from five to three major payers—Aetna, Anthem, and UnitedHealthcare. The CAP continues to effectively advocate on behalf of pathologists with private payers on a variety of issues and will continue to do so.

On July 24, Anthem announced an agreement to acquire Cigna in a transaction worth $54.2 billion. The merger covers 53 million medical members in commercial, government, consumer, specialty, and international franchises, according to Anthem. Anthem's Blue Cross Blue Shield products operate in 14 states and its Medicaid plans through the Amerigroup brand are found in 19 states. Cigna also has a broad portfolio of individual, state, and federal government consumer products.

On July 3, Aetna announced its $37 billion merger with Humana. The move would capture Humana's 14 million total members that include its growing Medicare Advantage membership currently at 3.2 million. The combined company would have 33 million medical members based on membership data from March 31, Aetna stated.

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The archived recording of the CAP's July 15 webinar "How to Host a Lab Tour" is available to view. Throughout this hour-long panel discussion, CAP experts offer training for pathologists interested in hosting a lab tour for their member of Congress. The webinar covers the planning and logistical details, as well as provides case studies from CAP members who have conducted tours.

View the archived webinar and download the slides to this presentation.

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